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Port of Waterford

Visitor/Contractor COVID-19 Questionnaire

Name*
DD slash MM slash YYYY

To ensure the Safety & Health of all people interacting with our locations in Ireland, visitors and contractors must complete this declaration form prior to entering our sites. If you indicate to us you have symptoms of COVID-19 OR you have been abroad in the last 14 days with exception to Northern Ireland you should not be at work. Where this is the case, you are prohibited from entering the site and advised to seek professional medical help/assistance.



To ensure the Safety & Health of all people interacting with our locations in Ireland, visitors and contractors must complete this declaration form prior to entering our sites. If you indicate to us you have symptoms of COVID-19 OR you have been abroad in the last 14 days with exception to Northern Ireland you should not be at work. Where this is the case, you are prohibited from entering the site and advised to seek professional medical help/assistance.

1. Have you visited any countries outside of Ireland excluding Northern Ireland?*
2. Are you suffering any flu like symptoms/symptoms of Coronavirus COVID-19?*
3. Are you experiencing any difficulty in breathing, shortness of breath?*
4. Are you experiencing any fever like/Temperature symptoms?*
5. Did you consult a Doctor or other medical practitioner?*
6. How are you feeling Healthwise?*
7. Have you been in contact with someone who has been confirmed or a suspected case of COVID-19 in the past 14 days?*
When on site, I agree to adhere to our on-site standard processes/procedures regarding infection control, i.e. social distancing, hand washing/hand sanitising and general coughing/sneezing etiquette?
This report will be sent to the Health & Safety Manager.

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